New York's patchwork system of home health care was designed as an alternative to more expensive nursing homes, but providers frequently operate with less oversight and even fewer consequences for delivering poor care.

The past decade brought booming business for more than 1,300 home care agencies registered with the state. Between 2007 and 2010, companies received more than $5.2 billion in Medicaid reimbursement, according to state records. In the same time period, more than 345,000 New Yorkers received home care through Medicaid — the largest payer for home care services in the state.

But along the way, cases of negligent and substandard care for patients have piled up. An analysis of thousands of pages of state inspection reports at 40 of the state's poorest-performing and most frequently reviewed agencies found that many suffer from similar problems.

Nurses often failed to adequately coordinate care for patients, the result of poor communication with doctors and case managers. Unlike a nursing home or hospital, home care requires caregivers to travel to patients' homes, making frequent coordination from the field critical to providing quality care.

Photo: Albany Times Union

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Aleydis Llovet of Staten Island, a quadraplegic with no feeling in her arms or fingers, suffered second and third-degree burns to her hands when a replacement home attendant, inexperienced in caring for paralyzed patients, washed Llovet's hands with scalding hot water. (Times Union / Matt Drange)

Aleydis Llovet of Staten Island, a quadraplegic with no feeling in her arms or fingers, suffered second and third-degree burns to her hands when a replacement home attendant, inexperienced in caring for

A complaint investigation conducted at VNA Albany on Sept. 27, 2011, found that in three out of three cases the agency failed to ensure that the aides' plan of care included instructions for how to meet specific patient needs. (Yi-Ke Peng / Times Union)

A complaint investigation conducted at VNA Albany on Sept. 27, 2011, found that in three out of three cases the agency failed to ensure that the aides' plan of care included instructions for how to meet

A complaint investigation conducted at VNA Albany on Sept. 27, 2011, found that in three out of three cases the agency failed to ensure that the aides' plan of care included instructions for how to meet specific patient needs. (Yi-Ke Peng / Times Union)

A complaint investigation conducted at VNA Albany on Sept. 27, 2011, found that in three out of three cases the agency failed to ensure that the aides' plan of care included instructions for how to meet

Lapses have gone undetected or, in many cases, unpunished by the Department of Health, the arm of state government tasked with overseeing home health agencies. Providers are not required to notify the department when patients experience sudden or unexpected changes in their condition, including death. And even when the state does learn about these incidents, it doesn't always act on the information, records show.

Take the Madison County Public Health Department's home care agency One of its patients told his nurse that he did not want to be left alone with his wife, who had physically abused him. The patient had called adult protective services about her in the past, a 2010 inspection report shows. Despite witnessing the abuse, a nurse never reported it to the patient's supervising nurse or his physician, the inspector found.

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A complaint investigation conducted at VNA Albany on Sept. 27, 2011, found that in three out of three cases the agency failed to ensure that the aides' plan of care included instructions for how to meet specific patient needs.

A re-licensure survey at All Metro Health Care on March 30 and 31, 2010, meanwhile, found that in three of eight patient records that the agency failed to review and revise physician orders every six months, the minimum requirement under Medicaid regulations. In six of the cases, the agency failed to obtain physician order when changes in a patient's status were indicated, something experts said was indicative of poor communication between the agency and doctor.

Source: NYS Department of Health

The state took no enforcement action against the agency.

Elder advocate Jack Halpern of New York City said that many complaints filed with the Department of Health go unaddressed, something he's experienced first-hand. A former nursing home administrator, Halpern has filed numerous complaints with the state in his more than 35 years working in the industry, and often gives seminars on how to combat elder abuse.

"They (Department of Health) don't have enough resources," Halpern said. "They are overwhelmed, and they can't do their job. There's just no follow up."

Little oversight

The number of health inspectors working for the state has decreased, going from 298 full-time equivalent employees in 2008 to 190 last year. Of those, 22 were assigned to oversee home care agencies — roughly one inspector for every 62 providers.

Fines from the state, meanwhile, were few and far between. From 2007 though 2010, three-dozen agencies were fined as a result of deficiencies, state records show. Of these, nearly two thirds amounted to $10,000 or less — a fraction of the $7 million, on average, that home care agencies took in from Medicaid during the same time period.

Department of Health officials say they do their best with the resources they have, but are quick to point out that they don't see themselves as adversaries.

"It's kind of a carrot and stick thing," said the state's home and hospice director Rebecca Fuller Gray. "They (agencies) know what their problems are, and we demand that they correct them. At the end of the day, we'd like to see compliance; we don't want to shut them down."

Even agencies that lie to the state sometimes get a pass. In 2008, the owner of Caring Hands Home Care Inc. on Long Island altered records to make it appear the agency held a staff meeting to address quality of care issues, an inspection report shows. (Agencies are required to do this at least once annually.)

The inspector found: "The meeting minutes dated 09/08/08 and 10/05/08 were identical minutes for the year 2006. The number "six" (6) in the date (2006) was altered and changed to an eight (8) (2008)."

Yet the state took no enforcement action against the agency or its owner, Brigit Durkin. When asked about the inspections during an interview earlier this year, Durkin said they were "a pain in the neck."

"They are very intimidating when they come in," Durkin said, adding that inspectors already visited her agency once this year. "I'm trying to run a business here. Just because I had deficiencies in the past doesn't mean I have them now."

Caring Hands continues to operate, which baffles home care consultant James Carey, who has advised the industry for more than 20 years on how to respond to problems identified by inspectors. Carey reviewed hundreds of state inspection reports for this story.

"You have to wonder how these guys are still open," Carey said in reaction to Durkin's report. A lot of home care agency owners, he added, "just dont have a clue."

An explosion of growth

Patients often find themselves in need of assistance after being released from a hospital or nursing home. This can range from long-term care needs, such as help preparing food, bathing, and other daily activities, to temporary assistance following surgery.

To meet this demand exists a growing field of nurses, home aides and attendants, who together comprise the bulk of the home health care workforce. It's up to these people, many of whom get paid minimum wage and work long hours, to rehabilitate and care for patients in order to avoid readmission to a hospital or assisted living facility.

At Progressive Home Health Services, Inc. in Manhattan, home attendants and aides often administered care to patients even though they were not qualified to do so. A 2007 inspection of the agency found this to be a common problem and noted that it left patients "at risk of substandard care."

In one 2006 case, a Progressive patient was found dead by her daughter, having suffocated from the liquid meal her home attendant fed her. The replacement aide had not been trained by the agency on how to feed the patient, a state inspector found, and the lapse was never recorded in the agency's incident log.

A complaint investigation four months later by the Department of Health found that Progressive's administration failed to adequately supervise staff and communicate changes in the patient's condition; the state never fined Progressive after the inspection.

Carey said it's common for agencies not to follow up on patient deaths, adding that many incidents can be prevented with better communication. Equally troubling, he said, was that the state did little or nothing in response.

"It basically slipped through the cracks," Carey said, adding that because of an increasingly older population, agencies are taking on more complicated cases. The trend of hospitals releasing patients "quicker and sicker" is only exacerbaing these issues, he said.

"It's not just a little old lady who has dementia anymore," Carey said. "It can be a lot more complex than that."

Repeat deficiencies

In many cases, care providers operated under lax oversight from the agencies they worked for and state officials overseeing them. Agencies that were found to have repeat deficiencies were allowed to stay open.

The state inspected Visiting Nurse Service of Rochester and Monroe County, Inc. five separate times between 2007 and 2009, including several complaint investigations. In one 2009 case, a patient was admitted to the agency with an ulcer that required wound care. When her condition worsened and the wound became "pungent," the patient's nurse failed to notify her physician, an inspection found.

Less than a month later the patient was readmitted to the hospital, where staff noted an "increased foul order (sic) and bloody drainage" of her wound.

In a separate 2008 case, a patient of the agency was assigned eight different nurses over a period of 10 visits, prompting a state inspector to note a failure to coordinate adequate care for the patient. Another 2007 inspection found that a patient had submitted a written complaint with the agency, but the director of patient services never documented it in internal logs — a violation of the agency's own protocol.

A 2007 complaint investigation of Visiting Nurse Service of Ithaca & Tompkins County, Inc., meanwhile, shows one case where a patient admitted to the agency for wound care treatment was sent to the emergency room because his leg was "covered in maggots." The inspector found that the case manager failed to coordinate care with the patient's physician, and continued to recommend the family be left in charge of administering wound care — even after the patient's daughter called the agency and said she was unwilling to assist with the care "because the wounds were hard to look at, and she did not have the stomach for it."

A January 2009 inspection of Gentiva Health Services in Liverpool, a suburb of Syracuse, found the agency failed to ensure the qualifications of staff, provide supervision or ensure effective communication. An inspector reviewed two employee files, and found that both staffers had a history of testing positive for tuberculosis and the agency lacked verification they were not active carriers of the disease — a violation of state law.

After reviewing the resume of the agency's director of clinical services, the inspector found that she "lacked the required experience for the position." In response to the report, the agency fired its director six days later, and replaced her with an "acting" director.

During a follow-up visit the same month, however, the inspector found that she, too, had no home care experience. "Evidence is lacking that the agency ensured that each of these candidates were oriented to the responsibilities of the position," the inspector wrote.

In another case involving Gentiva, the agency's failure to coordinate care preceded one woman's death. After being admitted to the agency for Alzheimer's, the patient had a fever and her blood pressure was so low that her nurse was "unable to hear" it, according to inspection reports.

The nurse never communicated these things with her physician. Four days later, the woman was taken to the emergency room and died. An internal review of the incident found no "significant issues" with the care.

Perhaps most troublesome was the agency's own understanding of the problems found by inspectors.

One of the requirements for agencies is that they review their internal procedures once a year. When Gentiva did this in 2007 it found "no issues," despite being cited the same year for 'Immediate Jeopardy' — a federal designation defined as a situation in which noncompliance "has caused, or is likely to cause, serious injury, harm, impairment, or death to a resident."

What's more, under "recommendations," the agency's director had written "none," state records show.

(The state only imposes fines for findings it deems most serious, which it calls "condition level." Fines vary in scope depending on the violation, and range between $500 and $2,000.)

When an inspector discovers an abundance of deficiencies, as was the case with Gentiva, the state often orders a follow-up review to ensure that appropriate changes have been made. If the agency still hasn't adequately addressed the issues by then, it is put on a "termination track," said director Fuller Gray.

In her nine years working for the department, Fuller Gray said, she's never terminated a home care agency.

No teeth

Part of the difficulty in managing home care agencies stems from a lack of resources at the state level, including a continued decline in the number of inspectors. Just as agencies subcontract some patient care duties to third parties, the Department of Health hires outside companies to help with oversight. They include IPro, a nonprofit organization focused on quality of care initiatives and headquartered just outside of New York City.

IPro senior director Alene Hockenstad warned that changes in New York's home health care industry are only going to worsen existing problems in the coming years. In April, agencies began transferring patients into a managed care system. Rather than letting individuals choose their own agencies, the neediest patients will be assigned to HMOs, which may restrict their choice of provider or the number of visits allowed, Hockenstad said.

"Everybody in government is stretched really thin," she said. "I mean, clearly, the oversight agencies have lost staff, and it's definitely problematic."

Researcher Sam Krinsky of the United Healthcare Workers East 1199 Union has noticed the same thing. Krinsky said the culture of home care differs vastly from that of nursing homes, which have received more attention in New York and elsewhere.

Statements of deficiencies issued to home care agencies by the Department of Health are "not something that we take seriously," Krinsky said.

"In nursing homes, the inspections are a big deal. There are a lot more regulations they have to comply with ... It's just a much more robust system," he said. "In home care, it's more of a review of paperwork. It [Department of Health] doesn't have any teeth."

Matt Drange is a recent graduate of Columbia University's Stabile Center for Investigative Journalism, and a contributing writer at the Maine Center for Public Interest Reporting. He can be reached at mattdrange@gmail.com.